Early development of local data dashboards to depict the substance use care cascade for youth involved in the legal system: qualitative findings from end users.

INTRODUCTION: Rates of substance use are high among youth involved in the legal system (YILS); however, YILS are less likely to initiate and complete substance use treatment compared to their non legally-involved peers. There are multiple steps involved in connecting youth to needed services, from screening and referral within the juvenile legal system to treatment initiation and completion within the behavioral health system. Understanding potential gaps in the care continuum requires data and decision-making from these two systems. The current study reports on the development of data dashboards that integrate these systems' data to help guide decisions to improve substance use screening and treatment for YILS, focusing on end-user feedback regarding dashboard utility. METHODS: Three focus groups were conducted with n = 21 end-users from juvenile legal systems and community mental health centers in front-line positions and in decision-making roles across 8 counties to gather feedback on an early version of the data dashboards; dashboards were then modified based on feedback. RESULTS: Qualitative analysis revealed topics related to (1) important aesthetic features of the dashboard, (2) user features such as filtering options and benchmarking to compare local data with other counties, and (3) the centrality of consistent terminology for data dashboard elements. Results also revealed the use of dashboards to facilitate collaboration between legal and behavioral health systems. CONCLUSIONS: Feedback from end-users highlight important design elements and dashboard utility as well as the challenges of working with cross-system and cross-jurisdiction data.

Initial Validation of a Computerized Adaptive Test for Substance Use Disorder Identification in Adolescents.

PURPOSE: Computerized adaptive tests (CATs) are highly efficient assessment tools that couple low patient and clinician time burden with high diagnostic accuracy. A CAT for substance use disorders (CAT-SUD-E) has been validated in adult populations but has yet to be tested in adolescents. The purpose of this study was to perform initial evaluation of the K-CAT-SUD-E (i.e., Kiddy-CAT-SUD-E) in an adolescent sample compared to a gold-standard diagnostic interview. METHODS: Adolescents (N = 156; aged 11-17) with diverse substance use histories completed the K-CAT-SUD-E electronically and the substance related disorders portion of a clinician-conducted diagnostic interview (K-SADS) via tele-videoconferencing platform. The K-CAT-SUD-E assessed both current and lifetime overall SUD and substance-specific diagnoses for nine substance classes. RESULTS: Using the K-CAT-SUD-E continuous severity score and diagnoses to predict the presence of any K-SADS SUD diagnosis, the classification accuracy ranged from excellent for current SUD (AUC = 0.89, 95% CI = 0.81, 0.95) to outstanding (AUC = 0.93, 95% CI = 0.82, 0.97) for lifetime SUD. Regarding current substance-specific diagnoses, the classification accuracy was excellent for alcohol (AUC = 0.82), cannabis (AUC = 0.83) and nicotine/tobacco (AUC = 0.90). For lifetime substance-specific diagnoses, the classification accuracy ranged from excellent (e.g., opioids, AUC = 0.84) to outstanding (e.g., stimulants, AUC = 0.96). K-CAT-SUD-E median completion time was 4 min 22 s compared to 45 min for the K-SADS. CONCLUSIONS: This study provides initial support for the K-CAT-SUD-E as a feasible accurate diagnostic tool for assessing SUDs in adolescents. Future studies should further validate the K-CAT-SUD-E in a larger sample of adolescents and examine its acceptability, feasibility, and scalability in youth-serving settings.

Neurophysiology of predictable unpleasant event processing in pre-adolescents and early adolescents, part II: Reflex and event-related potential markers of defensive reactivity and peripheral attention modulation.

The ability to anticipate and process predictable unpleasant events, while also regulating emotional reactivity, is an adaptive skill. The current article and a companion in this issue test for potential changes in predictable event processing across the childhood-to-adolescence transition, a key developmental period for biological systems that support cognitive/ emotional abilities. While the companion article focuses on neurophysiology of predictable event processing itself, the present article examines peripheral emotional response regulation and attention modulation that coincides with event processing. A total of 315 third-, sixth-, or ninth-grade individuals saw 5-s cues predicting "scary," "every day," or uncertain pictures, and here, blink reflexes and brain event-related potentials (ERPs) elicited by peripheral noise probes are analyzed. During the cue, blink reflexes and probe ERP (P200) amplitudes were increased when the cue predicted scary, compared to everyday, content. After picture onset, reflex enhancement by scary content then disappeared for predictable images, whereas ERP modulation was similar regardless of predictability. Patterns are similar to those in adults and suggest (1) sustained defensive response priming and enhancement of peripheral attention during aversive anticipation, and (2) an ability, even in pre-adolescents, to downregulate defensive priming while maintaining attentional modulation once an awaited predictable aversive event occurs.

Neurophysiology of predictable unpleasant event processing in preadolescents and early adolescents, part I: Event-related potential markers of unpleasant image anticipation and processing.

The ability to anticipate and process predictable unpleasant events, while also regulating emotional reactivity, is an adaptive skill. The current article and a companion in this issue test for potential changes in predictable event processing across the childhood-to-adolescence transition, a key developmental period for biological systems that support cognitive/emotional abilities. While the companion article focuses on emotion regulation and peripheral attention modulation in predictable unpleasant contexts, the current paper presents neurophysiological markers of predictable event processing itself. 315 third-, sixth-, or ninth-grade individuals saw 5-s cues predicting "scary," "every day," or uncertain image content; in this paper, cue- and picture-locked event-related potentials (ERPs) are analyzed. During the cue, early ERP positivities were increased and later slow-wave negativities were reduced when predicted content was scary as compared with mundane. After picture onset, a picture processing-related positivity was then increased for scary compared with everyday images regardless of predictability. Cue-interval data suggest enhanced processing of scary cues and reduced anticipatory processing of scary images-opposite to adults. After event onset, meanwhile, emotional ERP enhancement regardless of predictability is similar to adults and suggests that even preadolescent individuals maintain preferential engagement with unpleasant events when they are predictable.

Outpatient Opioid Prescriptions are Associated With Future Substance Use Disorders and Overdose Following Adolescent Trauma.

OBJECTIVE: This study aims to determine if outpatient opioid prescriptions are associated with future SUD diagnoses and overdose in injured adolescents 5 years following hospital discharge. SUMMARY OF BACKGROUND DATA: Approximately, 1 in 8 adolescents are diagnosed with an SUD and 1 in 10 experience an overdose in the 5 years following injury. State laws have become more restrictive on opioid prescribing by acute care providers for treating pain, however, prescriptions from other outpatient providers are still often obtained. METHODS: This was a retrospective cohort study of patients ages 12-18 admitted to 2 level I trauma centers. Demographic and clinical data contained in trauma registries were linked to a regional database containing 5 years of electronic health records and prescription data. Regression models assessed whether number of outpatient opioid prescription fills after discharge at different time points in recovery were associated with a new SUD diagnosis or overdose, while controlling for demographic and injury characteristics, and depression and posttraumatic stress disorder diagnoses. RESULTS: We linked 669 patients (90.9%) from trauma registries to a regional health information exchange database. Each prescription opioid refill in the first 3 months after discharge increased the likelihood of new SUD diagnoses by 55% (odds ratio: 1.55, confidence interval: 1.04-2.32). Odds of overdose increased with ongoing opioid use over 2-4 years post-discharge ( P = 0.016-0.025). CONCLUSIONS: Short-term outpatient opioid prescribing over the first few months of recovery had the largest effect on developing an SUD, while long-term prescription use over multiple years was associated with a future overdose.

Use of Project ECHO to promote evidence based care for justice involved adults with opioid use disorder.

Background: People with opioid use disorders (OUDs) are at heightened risk for involvement with the criminal justice system. Growing evidence supports the safety and effectiveness of providing empirically supported treatments for OUD, such as medications for OUD (M-OUD), to people with criminal justice involvement including during incarceration or upon reentry into the community. However, several barriers limit availability and accessibility of these treatment options for people with OUDs, including a shortage of healthcare and justice professionals trained in how to implement them. This study evaluated a novel education program, the Indiana Jail OUD Treatment ECHO, designed to disseminate specialty knowledge and improve attitudes about providing M-OUD in justice settings. Methods: Through didactic presentations and case-based learning (10 bimonthly, 90-min sessions), a multidisciplinary panel of specialists interacted with a diverse group of community-based participants from healthcare, criminal justice, law enforcement, and related fields. Participants completed standardized surveys about OUD knowledge and attitudes about delivering M-OUD in correctional settings. Thematic analysis of case presentations was conducted. Results: Among 43 participants with pre- and post-series evaluation data, knowledge about OUD increased and treatment was viewed as more practical after the ECHO series compared to before. Cases presented during the program typically involved complicated medical and psychiatric comorbidities, and recommendations addressed several themes including harm reduction, post-release supports, and integration of M-OUD and non-pharmacological interventions. Conclusions: Evaluation of future iterations of this innovative program should address attendance and provider behavior change as well as patient and community outcomes associated with ECHO participation.

Enhancing the Delivery of an Empirically-Supported Trauma-Focused Treatment for Adolescents: Providers' Views of the Role of Technology and Web-Based Resources.

This mixed-methods study assessed providers' views of the use of technology in the delivery of an empirically supported mental health treatment for adolescents (Trauma-Focused Cognitive Behavioral Therapy; TF-CBT). Thematic qualitative interviews were conducted with nine experienced providers. Emerging themes served as the basis for the creation of a quantitative web-based survey, completed by 56 TF-CBT experts, to assess the perceived helpfulness of the recommendations. Technology was perceived as a useful, appealing, and familiar tool that could greatly enhance the delivery of this treatment modality with adolescents. Main recommendations included the creation of a mobile application targeting all of the treatment components and a website with developmentally appropriate resources for providers, caregivers, and teens. Technology may be a useful tool for enhancing service delivery and promoting engagement among youth receiving trauma-focused mental health treatment.

Adolescent Substance Use Following a Deadly U.S. Tornado Outbreak: A Population-Based Study of 2,000 Families.

Despite conceptual links between disaster exposure and substance use, few studies have examined prevalence and risk factors for adolescent substance use and abuse in large, population-based samples affected by a recent natural disaster. We addressed this gap using a novel address-based sampling methodology to interview adolescents and parents who were affected by the 4th deadliest tornado outbreak in U.S. HISTORY: Postdisaster interviews were conducted with 2,000 adolescent-parent dyads living within a 5-mile radius of the spring 2011 U.S. tornadoes. In addition to descriptive analyses to estimate prevalence, hierarchical linear and logistic regression analyses were used to examine a range of protective and risk factors for substance use and abuse. Approximately 3% reported substance abuse since the tornado. Greater number of prior traumatic events and older age emerged as consistent risk factors across tobacco and alcohol use and substance abuse since the tornado. Tornado incident characteristics, namely, greater loss of services and resources after the tornado and posttraumatic stress disorder since the tornado, were associated with greater alcohol consumption. Service loss increased risk for binge drinking, whereas, for substance abuse, posttraumatic stress disorder increased risk and parent presence during the tornado decreased risk. Greater family tornado exposure was associated with a greater number of cigarettes smoked in female but not male teen participants. Both trauma and non-trauma-related factors are relevant to postdisaster substance abuse among adolescents. Future research should examine the role of broader ecological systems in heightening or curtailing substance use risk for adolescents following disaster exposure.

Clinician Perspectives on Treating Adolescents with Co-occurring Post-Traumatic Stress Disorder, Substance Use, and Other Problems.

Clinicians (n=138) who treat adolescents with co-occurring posttraumatic stress and substance use disorders (PTSD+SUD) were surveyed about their attitudes and practice behaviors. Most providers were trained in PTSD treatment; fewer were trained in SUD or PTSD+SUD treatments. PTSD+SUD treatment was rated more difficult than treatment of other diagnoses. Providers typically addressed symptoms of PTSD and SUD separately and sequentially, rather than with integrated approaches. There was no consensus about which clinical strategies to use with adolescent PTSD+SUD. Continued treatment development, training, and dissemination efforts are needed to equip providers with resources to deliver effective treatments to adolescents with PTSD+SUD.

Mental Health Among Adolescents Exposed to a Tornado: The Influence of Social Support and Its Interactions With Sociodemographic Characteristics and Disaster Exposure.

Approximately 25% of youths experience a natural disaster and many experience disaster-related distress, including symptoms of posttraumatic stress disorder (PTSD) and depression. This study contributes to the literature by examining PTSD and depressive symptoms among 2,000 adolescents (50.9% female, 70.5% White) assessed after exposure to tornadoes in 2011. The authors hypothesized that greater tornado exposure, female sex, and younger age would be associated with distress, and that social support would interact with these associations. Analyses showed that PTSD symptoms were associated with lower levels of social support (ß = -.28, p < .001), greater tornado exposure (ß = .14, p < .001), lower household income (ß = -.06, p = .013, female sex (ß = -.10, p < .001), and older age (ß = .07, p = .002), with a 3-way interaction between tornado exposure, sex, and social support (ß = -.06, p = .017). For boys, the influence of tornado exposure on PTSD symptoms increased as social support decreased. Regardless of level of tornado exposure, low social support was related to PTSD symptoms for girls; depressive symptom results were similar. These findings were generally consistent with the literature and provide guidance for intervention development focused on strengthening social support at the individual, family, and community levels.

Prevalence and predictors of PTSD and depression among adolescent victims of the Spring 2011 tornado outbreak.

BACKGROUND: Relatively few studies have examined prevalence and predictors of posttraumatic stress disorder (PTSD) or major depressive episode (MDE) in disaster-affected adolescents. Fewer still have administered diagnostic measures or studied samples exposed to tornadoes, a common type of disaster. Further, methodologic problems limit the generalizability of previous findings. This study addressed prevalence estimates and risk factors for PTSD and MDE among adolescents exposed to the Spring 2011 tornado outbreak in Alabama and Joplin, Missouri. METHODS: A large (N = 2000), population-based sample of adolescents and caregivers, recruited randomly from tornado-affected communities, participated in structured telephone interviews. PTSD and MDE prevalence were estimated for the overall sample, by gender, and by age. Hierarchical logistic regression was used to identify risk factors for PTSD and MDE. RESULTS: Overall, 6.7% of adolescents met diagnostic criteria for PTSD and 7.5% of adolescents met diagnostic criteria for MDE since the tornado. Girls were significantly more likely than boys to meet diagnostic criteria for MDE, and older adolescents were more likely than younger adolescents to report MDE since the tornado. Female gender, prior trauma exposure, and an injured family member were associated with greater risk for PTSD and MDE. Specific incident characteristics (loss of services, concern about others' safety) were associated with greater PTSD risk; prior disaster exposure was associated with lower MDE risk. CONCLUSIONS: However, most adolescents were resilient following tornado exposure, roughly 1 in 15 developed PTSD, 1 in 13 developed MDE, and many more endorsed subclinical mental health problems. Information regarding specific risk factors can guide early screening, prevention, and intervention efforts in disaster-affected communities.

Relations between trait impulsivity, behavioral impulsivity, physiological arousal, and risky sexual behavior among young men.

The current study examined how impulsivity-related traits (negative urgency, sensation seeking, and positive urgency), behavioral measures of risk taking and reward seeking, and physiological reactivity related to three different risky sexual behaviors in sexually active undergraduate men (N = 135). Regression analyses indicated that sensation seeking and behavioral risk-taking predicted unique variance in number of sexual partners. These findings suggest that, for young men, acquisition of new partners is associated with need for excitement and reward and willingness to take risks to meet those needs. Sensation seeking, behavioral risk-taking, and skin conductance reactivity to arousing stimuli was related to ever having engaged in sex with a stranger, indicating that, for men, willingness to have sex with a stranger is related not only to the need for excitement and risk-taking but also with innate responsiveness to arousing environmental triggers. In contrast, regression analyses indicated that young men who were impulsive in the context of negative emotions were less likely to use condoms, suggesting that emotion-based impulsivity may be an important factor in negligent prophylactic use. This study adds to the current understanding of the divergence between the correlates of risky sexual behaviors and may lend utility to the development of individualized HIV prevention programming.

A Statewide Consultation Helpline for Rapid Linkage to Services for Youths With Opioid Use Disorder and Other Substance Use.

OBJECTIVE: The authors examined the initial implementation of the Indiana Adolescent Addiction Access (AAA) program, modeled on the widely disseminated Child Psychiatry Access Program framework. The AAA program developed a statewide consultation helpline to connect health care providers with adolescent addiction specialists. METHODS: The AAA line was staffed by a coordinator, who fielded initial questions, and on-call clinical specialists (social workers, nurse practitioners, psychiatrists, and psychologists), who were paged to complete telephone consultations and provide care recommendations. When necessary, AAA providers offered urgent clinical assessments and initiated treatment. Descriptive analyses were performed for key variables over the first 21 months of AAA operations. RESULTS: From July 2021 to March 2023, a total of 125 consultations were completed. Most callers were health care providers (71%) or parents (27%). Calls pertained to youths ages 10-18 years (mean±SD age=16.4±1.3; 62% of callers were male, 84% White, and 11% Black), with concerns around cannabis (63%), opioids (38%), and other substances. About 26% of calls related to an overdose, and 41% of cases were rated as severe. Recommendations included starting new medications (17%) or outpatient therapy (86%), and 17% of consultations resulted in urgent evaluations. CONCLUSIONS: The Indiana AAA program helps overcome key barriers to adolescent substance use treatment. Increasing the capacity to initiate medication for opioid use disorder and other treatment rapidly through consultation and direct care is a promising, scalable approach for preventing overdose deaths among youths.

Psychiatric problems and trauma exposure in nondetained delinquent and nondelinquent adolescents.

This study examined the prevalence of and associations between specific psychiatric disorders, substance use problems, and trauma exposure in a sample of delinquent and nondelinquent adolescents. A nationally representative sample of adolescents (n = 3,614; M age = 14.5 years, SD = 1.7; 51% male; 71% White, non-Hispanic, 13.3% African American, non-Hispanic, 10.7% Hispanic) was interviewed via telephone about engagement in delinquent acts and their experience of posttraumatic stress disorder, major depressive episode, substance use, interpersonal violence, and other forms of trauma exposure. Delinquent adolescents were more likely than nondelinquent adolescents to experience trauma; they were also more likely to report past-year posttraumatic stress disorder, major depressive episode, alcohol abuse, and nonexperimental drug use. After accounting for the effects of demographics and trauma exposure, delinquency was associated with increased likelihood of posttraumatic stress disorder and problematic substance use in both genders and increased likelihood of major depressive episode in girls. Findings highlight substantial overlap among delinquency, trauma exposure, posttraumatic stress disorder, and major depressive episode in adolescents and the need for interventions that address these varied clinical problems. Future work should examine the factors underlying the development of these relations over time.

Associations of alcohol use disorder, cannabis use disorder, and nicotine dependence with concurrent opioid use disorder in U.S. adults.

Polysubstance use of alcohol, cannabis, and nicotine has been shown to be correlated with opioid use disorder (OUD). The goal of this study was to determine whether alcohol use disorder (AUD), cannabis use disorder (CUD), and/or nicotine dependence were associated with concurrent OUD. Data came from the 2015-2019 National Survey on Drug Use and Health (n = 282,768, 48.5% male). Weighted logistic regression was performed for experiencing OUD in the past year concurrent with AUD, CUD, nicotine dependence, all pairwise interactions, the three-way interaction, and demographic covariates. Compared to individuals with no substance use disorder (SUD), individuals with AUD had 5.24 times the odds (95% CI [4.25, 6.46]), individuals with CUD had 6.69 times the odds (95% CI [5.13, 8.72]), and individuals with nicotine dependence had 7.12 times the odds of experiencing OUD (95% CI [6.10, 8.32]). Individuals with either AUD and CUD or AUD and nicotine dependence had approximately 15 times the odds of having OUD than those with no SUD (95% CI [12.58, 19.53] and 95% CI [11.63, 18.19], respectively). Individuals with CUD and nicotine dependence had 27.35 times the odds of having OUD than those with no SUD (95% CI [21.88, 34.19]). Individuals with AUD, CUD, and nicotine dependence had 47.31 times the odds of having OUD compared to individuals with no SUD (95% CI [36.79, 60.83]). A multiplicative effect was present when two or more SUD occurred simultaneously and was greatest when all three occurred at once, which suggests that prevention programs or interventions aimed at OUD should focus on persons with multiple SUDs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Treatment of Adolescent Cannabis Use Disorders.

This review summarizes treatments for cannabis use disorder (CUD) in adolescents. The best supported CUD treatments are cognitive behavioral psychotherapies, including family-based models that facilitate environmental changes and youth-focused models that incorporate skills training, motivational interviewing, and contingency management to promote reductions in cannabis use. Some medications show promise in reducing cannabis craving and withdrawal symptoms. Further research is needed on the efficacy and implementation of existing treatments given the changes in cannabis use trends over time and on emerging technologies that may expand access to evidence-based CUD treatments.

Treatment of Adolescent Cannabis Use Disorders.

This review summarizes treatments for cannabis use disorder (CUD) in adolescents. The best supported CUD treatments are cognitive behavioral psychotherapies, including family-based models that facilitate environmental changes and youth-focused models that incorporate skills training, motivational interviewing, and contingency management to promote reductions in cannabis use. Some medications show promise in reducing cannabis craving and withdrawal symptoms. Further research is needed on the efficacy and implementation of existing treatments given the changes in cannabis use trends over time and on emerging technologies that may expand access to evidence-based CUD treatments.

Evidence-based Treatment for Substance Use Disorders in Community Mental Health Centers: the ACCESS Program.

A significant gap remains in the availability and accessibility of evidence-based treatments (EBTs) in community substance use disorder (SUD) treatment. This study describes a 2-year statewide training initiative that sought to address this gap by training community-based therapists in motivational enhancement/cognitive behavioral therapy (MET/CBT). Therapists (N = 93) participated in a 2-day MET/CBT workshop followed by bi-weekly clinical consultation, fidelity monitoring, guided readings, and online resources. Therapists completed pre-training and follow-up assessments measuring knowledge, attitudes, confidence, and implementation barriers. Most therapists attended 10 or more consultation calls. Submission of session recordings for feedback was the least utilized training element. Therapists reported increased confidence in their ability to implement MET/CBT for SUD and demonstrated improvement in MI and CBT knowledge. Therapists reported several implementation barriers, including lack of time and opportunity to treat patients with MET/CBT. Recommendations for future training initiatives and addressing the barriers identified in this study are discussed.

User-Guided Enhancements to a Technology-Facilitated Resilience Program to Address Opioid Risks Following Traumatic Injury in Youth: Qualitative Interview Study.

BACKGROUND: Youth with traumatic injury experience elevated risk for behavioral health disorders, yet posthospital monitoring of patients' behavioral health is rare. The Telehealth Resilience and Recovery Program (TRRP), a technology-facilitated and stepped access-to-care program initiated in hospitals and designed to be integrated seamlessly into trauma center operations, is a program that can potentially address this treatment gap. However, the TRRP was originally developed to address this gap for mental health recovery but not substance use. Given the high rates of substance and opioid use disorders among youth with traumatic injury, there is a need to monitor substance use and related symptoms alongside other mental health concerns. OBJECTIVE: This study aimed to use an iterative, user-guided approach to inform substance use adaptations to TRRP content and procedures. METHODS: We conducted individual semistructured interviews with adolescents (aged 12-17 years) and young adults (aged 18-25 years) who were recently discharged from trauma centers (n=20) and health care providers from two level 1 trauma centers (n=15). Interviews inquired about reactions to and recommendations for expanding TRRP content, features, and functionality; factors related to TRRP implementation and acceptability; and current strategies for monitoring patients' postinjury physical and emotional recovery and opioid and substance use. Interview responses were transcribed and analyzed using thematic analysis to guide new TRRP substance use content and procedures. RESULTS: Themes identified in interviews included gaps in care, task automation, user personalization, privacy concerns, and in-person preferences. Based on these results, a multimedia, web-based mobile education app was developed that included 8 discrete interactive education modules and 6 videos on opioid use disorder, and TRRP procedures were adapted to target opioid and other substance use disorder risk. Substance use adaptations included the development of a set of SMS text messaging-delivered questions that monitor both mental health symptoms and substance use and related symptoms (eg, pain and sleep) and the identification of validated mental health and substance use screening tools to monitor patients' behavioral health in the months after discharge. CONCLUSIONS: Patients and health care providers found the TRRP and its expansion to address substance use acceptable. This iterative, user-guided approach yielded novel content and procedures that will be evaluated in a future trial.